Even though you pay these expenses, they don t count toward the out-ofpocket limit.

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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $2,000 single/$4,000 family in-network. $6,000 single /$12,000 family out-ofnetwork. No. Yes. $6,250 single / $12,500 family innetwork. $12,500 single/ $25,000 family out-ofnetwork. Premiums, balance-billed charges, and health care this plan doesn t cover. No. Yes. See or call for a list of participating providers. No. You don t need a referral to see a specialist. Yes. See the chart starting on page 2 for yours costs for services this plan covers. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 6. See your policy or plan document for additional information about excluded services. 1 of 8

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions If you visit a health care provider s office or clinic If you have a test Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/ Immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) No charge Chiropratic care maximum of 20 visits 2 of 8

3 Common Medical Event Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at or you may call Generic drugs Preferred brand drugs Non-preferred brand drugs Retail: 25% Co-Insurance (minimum $4, maximum $20). Mail: 25% Co-Insurance (minimum $10, maximum $50) Retail: 25% Co-Insurance (minimum $25, maximum $60). Mail: 25% Co-Insurance (minimum $60, maximum $150) Retail: 25% Co-Insurance (minimum $40, maximum $90). Mail: 25% Co-Insurance (minimum $100, maximum $225) Not Covered Not Covered Not Covered Retail: Up to 30-day supply; Mail Order: Up to 90-day supply. Certain preventative drugs not subject to the deductible. Retail: Up to 30-day supply; Mail Order: Up to 90-day supply. Certain preventative drugs not subject to the deductible. Retail: Up to 30-day supply; Mail Order: Up to 90-day supply. Certain preventative drugs not subject to the deductible. Specialty drugs Same as Retail Co-Insurance for Generic and Brand drugs above Not Covered Specialty: Up to 30-day supply. Certain preventative drugs not subject to the deductible. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Preauthorization is Required If you need immediate medical attention Emergency room services Emergency medical transportation Urgent care 3 of 8

4 Common Medical Event Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions If you have a hospital stay Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance abuse disorder outpatient services Substance abuse disorder inpatient services If you are pregnant Prenatal and postnatal care Delivery and all inpatient services for first visit; No Charge Afterwards 4 of 8

5 Common Medical Event Services You May Need In-network Provider Out-of-network Provider Limitations & Exceptions If you need help recovering or have other special health needs If your child needs dental or eye care Home health care Rehabilitation services Habilitation services Not Covered Not Covered Skilled nursing care Durable medical equipment Eye Exam No Charge Hospice service Glasses Not Covered Not Covered Dental check-up Not Covered Not Covered Up to 120 days per calendar year. Preauthorization is required Covered as medically necessary; 60 day annual limit for occupation and physical therapy; 25 annual day limit for speech therapy Up to 100 days per calendar year. Preauthorization is required 1 Per calendar year 5 of 8

6 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Bariatric surgery - preauthorization is required Children's eye glasses and dental check-ups Cosmetic surgery - unless clinically eligible Dental care (Child and Adult) - unless due to treatment related to accidental injury within 12 months of an accident Habilitation Services Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Routine foot care Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Children's eye exams Chiropractic care - up to 20 visits per calendar year Hearing aids Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under this plan. Other limitations on your rights to continue coverage may apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Aetna Intermediate Plan at Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. 6 of 8

7 Coverage Examples Coverage for: Individual/ Family Plan Type: Aetna Premier Care Network About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $4,330 Patient pays $3,210 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: s $2,000 Copays $0 Coinsurance $1,060 Limits or exclusions $150 Total $3,210 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5400 Plan pays $2670 Patient pays $2730 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: s $2,000 Copays $0 Coinsurance $650 Limits or exclusions $80 Total $2,730 7 of 8

8 Coverage Examples Coverage for: Individual/ Family Plan Type: Aetna Premier Care Network Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa Chinese ( 中文 ): 如果需要中文的帮 助, 请拨打这个号码 Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' of 8